Five years ago there were a couple dozen stand-alone emergency centers in Texas, and now there are more than 200. Colorado, Ohio and other states also have seen steady growth.

As these centers offer another choice for people tired of deflating wait times at hospital emergency rooms, their escalating numbers are sending ripples across the health-care field. Critics say they do little to help those in rural America with dire medical needs, siphon away skilled emergency physicians and too often stick patients with overinflated bills.

Groups such as the Texas Association of Freestanding Emergency Centers counter that people are getting an unprecedented level of care as the centers open close to consumers, don't keep them waiting, provide an ER physician around-the-clock, and are equipped for any medical emergency.

Researchers with Brigham and Women's Hospital in Boston conducted a study that found the number of stand-alone emergency departments grew from 222 in 2009 to 360 across 30 states as of March 2015. The most are in Texas, which in 2009 adopted a law that allowed private, for-profit ventures to provide the kind of emergency services that hospitals do.

"The idea of delivering fast, quick, high-quality emergency care ... is very innovative," said Dr. Jeremiah Schuur, lead author of the Brigham and Women's study published last month.

The freestanding ERs locate in zip codes with an attractive payer mix, Schuur said, meaning ones where more people are privately insured, have higher incomes and there are fewer Medicaid reimbursements. They're more likely to open in parts of Texas already served by traditional hospital emergency rooms, he said.

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"Depending on your viewpoint, they offer competition or a duplication of services," Schuur said.

There doesn't appear to be market incentive for many of the stand-alone centers to open in rural areas that are home to poorer populations. At least 45 hospitals in less populated parts of the U.S. have closed since 2010, and a quarter of those were in Texas, according to the Texas Organization of Rural and Community Hospitals.

So far, the freestanding ERs have not filled the void left by those closings.

"It is important for policymakers to know that this is a service that's locating to serve one part of the population and not everyone," Schuur said.

A spokesman for the Texas Association of Freestanding Emergency Centers did not return phone messages seeking comment, but John McGee, an association board member, told The Dallas Morning News this month that rules dictating federal reimbursement rates and other regulatory hurdles make it difficult to open locations in poor areas.

As hospitals face greater competition in providing emergency services, they're also finding it more difficult to retain skilled ER doctors. Grant Douglass, president of Southwest Medical Associates, which contracts with hospitals and clinics in primarily rural parts of Texas to provide ER physicians, estimates that at least 1,500 doctors have been lured from Texas hospitals with the promise of better pay, less stress and a smaller volume of patients.

"It's created a tremendous strain on us to staff the small rural (hospitals)," Douglass said, adding that his company often must double the pay of doctors to ensure it can provide adequate staffing levels for hospitals.

But drawing the greater attention from consumer advocates are higher billing rates that can be found at freestanding ERs when compared to urgent care centers.

An analysis by the Colorado-based Center for Improving Value in Health Care found the cost of treatment at an emergency facility exceeded the rates at an urgent care center by $400 to more than $800. And of the top 10 reasons Coloradans used a stand-alone ER in 2014, seven were for nonlife-threatening conditions like sore throats and bronchitis.

"People are going to these freestanding emergency departments for non-emergent care," said Jonathan Mathieu with CIVHC. "It's for things that could likely wait."

McGee, with the Texas Association of Freestanding Emergency Centers, argues that freestanding centers are an industry simply meeting a demand. People are tired of having to wait hours at a hospital ER, he said.

But Vivian Ho, a health economist with Rice University's Baker Institute, counters that the motive is "people in the health care industry out to make a buck."

What's needed is a combination of legislation that provides greater oversight and consumer education programs so that people can learn to discern one medical clinic from another, she said.

"These places are so disarming," she said. "I mean, they're in shopping centers all over Texas."

(KA)

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